Game Based CBT for Child Abuse & Trauma

0:04 Good evening and welcome. Thank you so much for joining us for tonight’s webinar, Game-Based CBT for Child Abuse and Trauma, presented by Dr. Justin Mizerel. 0:13 My name is Katie Delaney, and I’m the Family and Medical Outreach Coordinator for the New Jersey Center for Tourette Syndrome and Associated Disorders. I will be your facilitator for this evening. 0:23 Before I introduce our presenter, I want to go over some housekeeping notes. 0:27 The audience is muted. 0:28 If you are attending the live webinar, questions can be submitted in the questions box at the bottom of your screen. 0:34 During the live Q &A, the audience will gain access to and mute themselves. 0:38 We will start recording right before this. 0:41 At the top right of your screen, you’ll see a paperclip icon. 0:44 There you’ll find a copy of the slides and upcoming events. 0:47 At the bottom of your screen, you will see a react button. 0:51 To the right of it is an arrow. 0:52 When you click the arrow, you’ll see a few emojis appear such as a heart, thumbs up, etc. 0:57 Throughout the webinar, feel free to use this feature to let a presenter know how they’re doing. Give me a thumbs up if that sounds good to you guys. Okay awesome, thank you. 1:13 So for those viewing the webinar recording, you will not have access to these features. 1:18 However, any questions you have for the presenter can be submitted through the chat box to the left of your screen. 1:24 The presenter will answer those questions on our webinar blog located on our website njcts.org under the programs tab. This blog will be monitored until a Tuesday, March 4th. 1:34 Any personal information will not be included. 1:37 The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors and employees assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. 1:49 We do not endorse any recommendation or opinion made by any member or physician, nor do we advocate any treatment. You are responsible for your own medical decisions. 1:57 Now, it is my pleasure to introduce our speaker for this evening, Dr. Justin Miserale. Dr. 2:03 Miserale is a licensed psychologist in New Jersey and New York and New Jersey. Dr. 2:11 Miserale received his undergrad degree from Rutgers University and his graduate degree from Fordham University. 2:18 He currently serves on the faculty at the Hassenfeld Children’s Hospital at NYU’s is NYU Langone’s Department of Child and Adolescent Psychiatry’s Child Study Center and is a clinical director at the department’s New Jersey office. 2:35 That is a mouthful. 2:36 It is a mouthful, yeah, I apologize. 2:39 No worries. 2:40 Dr. Mujerrell, health care is all yours. 2:44 No, that’s okay. 2:44 All right, yeah, thank you very much, Katie. 2:47 So tonight I’ll be talking about game-based cognitive behavioral therapy. 2:51 This is a therapy model that a colleague of mine and I developed a number of years ago, my colleague Craig Springer, when we were working at North Beth Israel Medical Center. 3:03 In that location, we were working with children and families who had been impacted by child abuse and maltreatment. 3:10 And it was a specialty clinic where children were referred from the Department of Child protection from state agencies. 3:21 These were families who were involved in the courts in various capacities. 3:25 These were children who had experienced various forms of trauma. 3:29 And unsurprisingly, people don’t want to necessarily deal with trauma. 3:33 It could be uncomfortable. 3:35 It could be upsetting, especially sexual trauma. 3:37 Disgust in therapy. 3:39 It can also be difficult and uncomfortable for therapists to engage in that kind of therapy. 3:45 So, what we had developed over the course of our time there was a model that would be a little bit easier, if you will, to handle, a model that would make it easier, more appealing, and more engaging for both the children and families to engage in the therapy as well as the therapists. 4:04 So, we’re going to be talking about that tonight. 4:07 And let’s get on to the next slide. 4:13 We’ll start by talking about childhood trauma. 4:15 So childhood trauma is defined here as an intense event that threatens a child’s physical or emotional well-being. 4:23 This is something that has to be directly experienced or observed. 4:27 We’re talking about in order to get classified as PTSD, these are things that need to be experienced as something that’s very invasive and very perhaps life-threatening and upsetting. 4:39 There are many different types of traumas that children encounter, unfortunately, including sexual abuse, which we define as anyone giving unwanted touches, inappropriate touches, trying to touch or look at a child’s private parts or make them touch or look at their private parts. 4:54 It also includes sexual trafficking and exposure to ***********. 5:00 Physical abuse, which involves using physical means of punishment or hitting or causing physical injury to a child that leaves marks and bruises on their body. 5:15 Neglect, meaning, you know, parents who are not giving proper shelter or care for them, for the child, educationally or medically. 5:24 Domestic violence, which involves interpersonal violence among parents and others in the home. 5:30 Community violence, which includes, you know, witness to shootings and gang violence. 5:36 medical trauma, which involves children going through difficult procedures medically, it could be for cancer or for other serious illnesses, natural disasters, exposure to wildfires, floods, hurricanes, and traumatic grief, which involves losing a close person and having traumatic bereavement, like difficulty moving past the sudden loss of a caregiver or someone very close to So there’s a lot of different forms of child trauma that we observe in the clinic. 6:08 Incidence rates, so it’s unfortunately common for children to experience some of these forms of trauma. 6:16 More than two-thirds of children are experiencing at least one potentially traumatic event of some sort. 6:23 PTSD, however, is experienced as high as 15 percent in children who have experienced a traumatic event. 6:30 And the important thing to take away from that is that if a child has experienced trauma, it’s not necessarily the case that they will be meeting criteria for PTSD. 6:42 PTSD, or post-traumatic stress disorder, is a formal diagnosis from the DSM, and you need to meet certain criteria to meet that. 6:51 Do not all traumas lead necessarily to PTSD. 6:55 There’s a lot of other factors that are involved, including protective factors. 6:59 For example, if a child experiences a traumatic event but they have very supportive caregivers and there’s a removal of the stressor or they’re not exposed to ongoing chronic repeated traumatic stress and they get proper treatment in a timely manner, it’s likely, it’s possible that they will heal and move on without developing full-blown PTSD. 7:24 So just because a child is exposed to trauma does not necessarily mean that they’re going of the developing PTSD. 7:31 Another important thing to mention here is the role of traumas, also sometimes called adverse childhood experiences. 7:40 There’s a huge study that has taken place called the ACEs study, A-C-E-S. 7:45 ACEs study studies adverse childhood experiences. 7:49 And what we know from that is that the more of these experiences you have, it’s actually quite intuitive. 7:53 The more of these experiences you have, the more likely that you are as an adult to experience a whole range of difficulties from depression, anxiety, substance abuse, incarceration, all kinds of difficulties, medical problems, you name it. 8:08 So it’s kind of an obvious and intuitive thing, but at this point in the state of our knowledge regarding human development that the more trauma, more adverse experiences you have in your childhood, the more likely it is that you’re gonna be dealing with these difficulties in adulthood, children, which then highlights the importance of intervention and therapy. 8:31 Impact of trauma on children. 8:33 Trauma has sort of this like bookshot effect, so if there’s a traumatic event, it can lead to various different kinds of presentations clinically. 8:43 It’s not a one-to-one model, so there could be PTSD symptoms, which is like avoidance of triggers or things that remind you of the trauma. 8:50 There can be things like hypervigilance, worrying about something happening or, you know, being attacked or assaulted, looking over your shoulder, hyper-awareness, and hyper-arousal as well, just like constantly being keyed up and on edge. 9:05 There’s also internalizing symptoms, like your classic anxiety and depression. 9:10 Externalizing behaviors, which is like your distress is manifested outwardly, externally, so you’re acting out, children acting out, not following directions, engaging in disruptive behaviors. 9:22 School problems can occur, maladaptive beliefs, attributions, and cognitive distortions. 9:28 What does that mean? 9:29 That means a child developing unhealthy or unwanted views of themselves or feeling insecure, low self-esteem, thinking that the world’s out to get them, thinking that other people are hateful or evil or bad and we can’t trust anybody, so we can actually distort the way a child starts to look at the world and themselves. 9:51 and sexual trauma specific behaviors such as sexually inappropriate behavior or violent and acting out a behavior that can happen subsequent to some kind of sexual abuse or sexual assault. 10:06 Common challenges faced when working with families following trauma. 10:10 So, you know, given all of these different possible presentations, difficulties among children who have encountered trauma, families are obviously impacted. 10:20 Many times the family themselves have experienced the trauma or they are wrapped up in the trauma. 10:26 For instance, if there is like a stepfather that was sexually abusing a child, like that’s going to impact the family dynamic. 10:32 Sometimes there is family separation, like there is abuse and now you can’t see certain relatives or now you can’t see one parent or the other parent. 10:40 There’s a lot of disruption that happens when these things, when these instances of abuse are disclosed because now child protective services might get involved and someone might need to be removed or that might be a temporary separation while the investigation takes place. 10:55 So lots of disruption happens to families. 10:58 So what families are dealing with all this, they’re dealing with diverse symptomatology. 11:03 So they’re coming to us in these clinical settings with a lot of challenge to begin with. 11:09 And now you throw into other things like other considerations to have, such as treatment receptivity. 11:14 Not all people are open to therapy. 11:17 There’s some people who don’t believe in therapy, there’s some people who are, you know, some children are not mature for really effective therapy or they may not be developmentally able at that point in their life to really engage with it. 11:30 But finding people who are ready to do the work, that can be a challenge. 11:34 Cultural factors may play too. 11:36 There’s different cultural groups have different levels of trust of the system and of professionals. 11:42 They may or may not be so open to it and that’s something that clinicians need to be sensitive to and aware of and be able to address those concerns as they come up. 11:50 And then logistical and pragmatic challenges occur. 11:53 For example, access, like if you’re a family who’s experienced trauma, like where do you go for therapy? 11:59 How do you find therapists? 12:01 It’s not so easy. 12:03 It’s not as easy as just opening up a phone book. 12:05 Phone books don’t even exist anymore, right? 12:07 You go online, you Google it up and you look for, how do you know who’s a good therapist? 12:12 There’s logistical issues as well, like how do you get there if you don’t have a car, or you need to take a bus, or if kids have other events and things. 12:22 And there’s all kinds of stuff that families with young children encounter. 12:26 So doing trauma work or child abuse work with families with young children have a lot of complex elements to it that need to be considered when doing the therapy. 12:37 Evidence-based practice for childhood trauma. 12:40 At this point in the state of the field, We’ve identified certain key areas of psychotherapy that are effective for most children who have experienced child abuse and trauma. 12:52 These are primarily expressed in the cognitive behavioral therapy field, so things like psychoeducation, emotional regulation, processing trauma, helping children in a time-limited, goal-oriented way to develop coping skills and face their trauma through different activities of what we call exposure therapy that I’ll get into as we go along with this presentation. 13:18 We’ve also identified that the inclusion of caregivers in the therapeutic process is absolutely critical. 13:24 If you have at least one supportive caregiver there to provide a comforting and supportive ear, they can be a great protective factor and really help with the healing process. 13:37 This work, the research in this area has also highlighted the importance of being culturally responsive, so being understanding of where people are coming from, their levels of trust, their views of the world depending on their racial, ethnic, and cultural backgrounds. 13:54 So this brings us to where we’re at today with the game-based presentation. 13:58 So the question that my colleague and I had was how do games, how can games, structured therapeutic games be used as a way to enhance evidence-based treatment for children and families? 14:09 Since we have been identifying the elements of therapy that are effective, how can we use games or what other modes of expression can we use to get people more engaged and involved to make therapy work more comfortably and to make, you know, parents feel more comfortable coming in and participating and also to help therapists have some concrete activities that they can do in order to facilitate the therapy. 14:41 Austin, would you want me to launch the first poll? 14:45 Sure, launch the first poll. 14:46 This is a good spot for polls, go ahead. 14:49 Okay, cool. 14:53 Okay, so I just launched it. 14:54 When you hear game next to CBT, what do you think of? 14:58 And I’ll just leave this up for a few seconds. 15:01 And you can give me cues, I guess, because I don’t I don’t have a particular like break point for the different polls. So if you see a spot to jump in, just be my guest. Okay. 15:25 Yeah, no, I definitely will. Thank you. Okay, so I’m gonna give it a few more seconds. 15:32 But so far the winner the winner is an interesting therapy strategy. Okay. 15:43 So we had when you game next to CBT, what do you think of? 15:47 We had 11% say board game and card games like Sorry and Connect Four. And then we had 89% say an interesting therapy strategy. 15:56 All right. 15:57 So we will continue and you will, you know, find the next opportunity to do the poll. All right. Game-based behavioral therapy. 16:05 So game-based CBT or GBCBT as we shorten it is a combination of cognitive behavioral therapy plus structured play therapy. 16:13 And I’m about what is structured clay therapy. 16:17 Skin-based cognitive behavioral therapy has four specific pillars. 16:20 One is that it’s data-driven, meaning that we like to collect standard measures either before, during, and after therapy. 16:28 So that includes things like child behavior checklists or trauma symptom checklists, questionnaires and measures that therapists and psychologists will often use. 16:38 Using that data to inform you about what does the clinical picture look like, like trauma, child abuse, it leads to various symptoms, various symptom presentations, and we need those questionnaires. 16:51 They’re very helpful to give us a sense of where the problem areas lie. 16:56 Game-based TBT is also based on evidence-based principles and behavioral modification strategies that have been time-tested for decades. 17:06 Directive and structured. 17:07 So each session has a certain amount of time, length that we’re covering it. 17:13 We use role plays, we use games, and they’re all rule-governed and they’re goal-oriented so it’s not just like a kind of make it up as you go along free-flowing thing. We have a plan going into each session. 17:22 We know what we’re gonna do and it’s gonna have a certain structure and a flow to it which I’ll be describing. 17:28 Making therapy fun and engaging is a major part of this whole thing. That’s the reason why we got into this. 17:34 I mean Trauma focused CBT, TF-CBT is the gold standard approach to childhood trauma and that’s been around for a long time. 17:43 We brought in game structured play and game based play as a way to make that trauma focused CBT like kind of more engaging and fun in a different kind of way. 17:54 But that’s kind of the advantage that this approach has over maybe other ones. 18:00 Experiential Game-based CBT definitely provides multiple opportunities to learn, practice, and demonstrate skills and it provides opportunities for kids to try stuff out through role play or through rehearsing the skills in the games with their parents and also with their therapist. 18:19 So we find that children learn best by doing and that’s where the experiential learning is key. 18:28 All right, components of GVCBT. 18:30 So each game-based CBT session is comprised of these different components. 18:35 So there is a session structure We go over token economies, which are reward systems that I’ll talk about we go over behavioral expectations Each session will have role plays that we do we call them skill skits There’s psycho education where we teach about you know certain concepts and your management relaxation What have you and then each session of course has the structured therapeutic games? 18:58 that’s the game part of the game-based CBT. 19:04 Session structure. 19:06 So reward systems. 19:07 We have two reward systems going on in both the individual version of game-based CBT and the group version of game-based CBT. 19:15 So with the reward systems, the first one is what’s called a fixed interval economy. 19:21 This is kind of like behavior management jargon. 19:24 We call it the star awards, and I’m going to show you a sheet so it looks more clear to everybody. 19:29 So what we use here is what we call the three golden rules of behavior management, which are follow directions, control your body, and be polite. 19:40 Any potential behavior infraction during therapy can fall into one of those three categories. 19:45 So if you’re not listening to what we’re telling you to do, you’re not following directions. 19:48 If you’re jumping up and down and moving around, you’re not controlling your body. 19:52 If you are being rude and you’re laughing when someone made a mistake or you’re not playing nicely and you’re not being a good sport, then you are not being polite. 20:01 So these are the three golden rules and the kids that are in the therapy need to follow them if they want to get a star award prize at the end. 20:09 The other system is a variable ratio economy, which is super checks that we’ll use in individual slash family therapy and the super bucks that we use in the group therapy. 20:19 These are just simply check marks on a piece of paper that I’ll show you or actual bucks that you can get that can then be cashed in for prize later on. 20:29 And we use the token economies, the reward systems, to gamify the whole session. 20:33 So they are trying to earn these different tokens, the checks and the bucks, in order to get something at the end of the session. 20:41 And I’m gonna tell you about what that is when we get there. 20:44 All right, so here’s what the fixed interval token economy system looks like. 20:49 This is a star award short. 20:50 So basically I’ll have this star chart. 20:52 You see that on the left hand column, there’s a session numbers there. 20:57 And what we do is I’ll usually write down the date of the session. 21:01 I’ll say, okay, do you remember the three rules at the beginning of the session? 21:04 And the child will say, okay, yeah, I do. 21:07 Follow directions, give me an example. 21:08 Control your body, what does that mean? 21:11 Be polite, give me an example of that. 21:12 If you follow the three rules at the end of the session, we’re gonna go over it all again. 21:16 And if you get all three stars, you get a prize from the prize box. 21:19 Typically we have like a prize box in the office. 21:25 and also in the in the group room and that’s filled with different like small tchotchkes and things that you get from like oriental express in bulk or something like that or from Amazon so they’re working hard these are kids in the elementary school age range primarily this is like five years old to ten or eleven years old so that’s the sweet spot for game-based CBT for this kind of therapy at the end if they get all three they earn a prize from the however if they’re getting off track if they’re not following directions if they’re you know arguing and they’re they’re being rude then they’re not on track we’ll say hey I want you to remember to follow directions if you don’t follow directions I can’t give you a prize today I want to see you get a prize who will provide the therapist with some behavior management guardrails or they can gently remind the child to get back on track if they’re getting off track okay variable ratio token economy so this is a super check tally chart This is what the the other system looks like. 22:26 So this is happening at the same time Whereas the star chart you go over everything in the beginning and then you check in with them at the end to see if they earn the prize the Super check system or the super book system that’s going on throughout Whenever we see the child doing a really good job Playing the games if they did a good job if they they’re giving really good answers in the games or if they’re winning the games they get a super check, or they get two super checks, or they could get five super checks. 22:54 If they earn all the super checks, you get all 20 super checks, and at the end of the session, they get to pick some activity that they wanna do for fun, and that could be like a regular game, like a board game, like sorry, like trouble, like scattagories, what have you. 23:13 These are things that they can, that they’re typically excited about earning. 23:18 So this is our way of gamifying the whole process. 23:23 So they are doing great during the session and they’re getting these points or these super checks that could then be cashed in for prizes at the end and for extra play time doing fun things they might want to do at the end with either the therapist or the caregiver. 23:36 So there’s incentives and incentives matter, incentives are fun. 23:42 All right, psychoeducation. 23:43 So psycho-ed is a huge part of CBT, no matter what the CBT is. 23:48 Just teaching somebody about what they’re dealing with, what their disorder is, or what their condition is, is incredibly helpful in healing. 23:56 We do education about social-emotional skills. 23:59 We give, for example, anger management, relaxation training, expressing emotion. 24:05 We also provide education about specific traumas, be it sexual abuse or physical abuse. 24:12 During psycho-ed, we talk to kids in a child-friendly way about how trauma or abuse might be impacting them mentally and emotionally and behaviorally. 24:23 Just learning certain things like if you’ve experienced sexual abuse, learning that you’re not alone and this happened to a lot of people and that there’s definitely a way to get through it and to work through it. 24:35 Just learning that and knowing that is incredibly healing. 24:40 role plays. So role plays, we call them skill skits. 24:45 What we say is we kind of go over what we’re gonna do and when we’re gonna when the therapist and the kids are ready to go we say ready set showtime. 24:54 And that lets everyone involved know that now we’re acting and we’re gonna act out something. 24:58 So an example might be let’s act out how we can handle a situation when someone makes us angry. 25:04 So during the psycho ed section maybe we teach about anger management, we teach about deep breathing and doing like what we call a bear hug. 25:11 We take deep breaths in through our nose, out through our mouth. 25:15 And then we’ll do a role play or a skill skit. 25:17 And then during that, what will happen is like, let’s pretend that we are kids on the playground and we’re gonna make each other mad. 25:23 We’re gonna insult each other. 25:24 And then instead of like continuing to insult each other or punching each other, we’re gonna take deep breaths, calm down and make a better choice, like either ignore the other person or apologize and make up. 25:38 So we kind of role play different scenarios and by role playing it, it reinforces the learning. 25:44 And of course they could get super checks in the individual session or super bucks in the group session and those things then count towards incentives that they can earn at the end. 25:55 We also integrate parents into these role plays during the session just so that there’s an opportunity for them to learn how to engage in these skills. 26:07 Alright, and now structured therapeutic games. 26:10 So structured therapeutic games are original games, I’m going to go over a few examples of them. 26:16 These are games that we’ve developed, they’re original therapy games, they can take various forms, they can be in the form of card games, trivia games, races, board games, some games that are just completely out of thin air that we’ve just made up. 26:30 Some games are cooperative some competitive and they’re designed each of them designed to provide multiple opportunities to rehearse and practice the skills that we’re teaching something to note is that they’re not just like a regular board game like Connect for or uno or monopoly like those are board games Those are cool games and those are games that a kid might earn time to play at the very end of the session if they Earned all their superchecks, but those are not the structured therapeutic games that I’m talking about All right, treatment modalities. 27:05 So treatment modalities come in two forms, the group and the individual. 27:08 And when I say individual, I mean individual slash family because in the structure of those sessions I’ll explain, they involve both child and caregiver at various points. 27:20 Okay, so we have various group therapy models for different age groups. 27:25 We have a caregiver group manual, And we also have different manuals for physical abuse and for sexual abuse. 27:37 The sessions for group are 12. 27:40 And when we were doing this work in contract with DCP &P, they were 90 minutes each. 27:46 That can be flexed down to be like 45 minutes or 60 minutes. 27:50 You just have to kind of move quickly through the curriculum. 27:53 It really depends on your model of billing and what your contracts are allowing you to do. 28:00 When you do this work with DCP &P, fortunately, they will cover for 90-minute sessions. 28:06 The sessions cover all the major treatment topics, but for a specific or finite period of time. 28:11 So there’ll be one session on anger management, whether or not all the kids have gotten it. 28:17 And that’s a bit different from how it works in the individual and in the individual slash family model. 28:22 So, in the individual model format, we have three different manuals or age groups, elementary, middle, and high school. 28:31 The modules, and modules are different from manuals. 28:34 Modules are like conceptual sections, so a conceptual section might be emotional regulation or emotional identification or child abuse education, so these are like topic areas. 28:46 And within each topic area or module, there’s various games and activities that the therapist can select to use. 28:53 They can use these games depending on the client’s needs. 28:57 If there’s a child who’s pretty good with emotional expression, then you don’t have to do so many emotional expression games. 29:04 But if you do have a kid who struggles with that, then you might want to spend an extra session on that. 29:10 Same goes for anger. 29:11 If there’s anger issues that are not easily resolved, maybe you want to do an extra session on anger management. 29:16 Maybe you want to repeat and rehearse some of the games and activities that you’ve already with them. 29:21 The individual model allows you to tailor it that way as opposed to the group because the group everybody is in there and they’re all following the same curriculum just like a class in school so it’s one thing after the next building on each other. 29:35 All right so the time spent on each treatment component is really dependent on the client’s skill and their level of maturity and the different issues that they’re confronting. 29:46 The treatment duration is also client-driven meaning How will they how they resolve these issues? How how quickly they are improving in their different symptoms? 29:56 It can range from six sessions of 14 sessions. 29:58 It could go away up to 20 sessions or more depending on how Complex the trauma is and how difficult and grained those symptoms are Okay Gamebase CBT has two broad what we call broad interventional components. 30:16 So the first Component is always social and emotional learning. 30:21 Social emotional learning is really like the bedrock of all cognitive behavioral therapies for children. 30:27 Even like Ticks and Tourette’s work, if you go to the CBIT manual, they do a lot of social emotional learning stuff. 30:34 That encompasses coping skills, emotional regulation skills, identifying your feelings, expressing your feelings. 30:40 No matter what the CBT is for kids, you’re doing that. 30:43 So, just like in all these other models, game-based CBT starts with the foundation of social-emotional learning. 30:51 And then the second half of game-based CBT for child abuse and trauma deals with trauma-specific skills and topics. 31:00 So, here’s a list of some of the, well, here’s a list of the different social-emotional learning skills that you get in GBCBT. 31:09 So, the first step is rapport building. 31:11 In order to do effective therapy, you have to build rapport, you have to build up that therapeutic relationship. 31:17 We have games that help facilitate that. 31:19 The next step is personal space and boundaries. 31:22 We have children who have experienced boundary violations, they might have been sexually abused, they might have been reinforced to act in sexual ways, they might have come from violent homes, so they might come with aggression and physicality. 31:36 So, we have to spend a session or later on, at least one session, limiting or specifying the limits of personal space and boundaries and setting those limits and ground rules. 31:49 Emotional identification and expression. 31:52 These are important for getting kids to talk about feelings, just like benign, regular feelings, non-traumatic feelings, just getting in the mode of being comfortable talking about of stuff in therapy with a therapist. 32:09 Then we have linking feelings to experiences. 32:11 So understanding the connection between thoughts, feelings, and behaviors. 32:16 To coping with difficult emotions and negative thoughts. 32:19 That’s like cognitive coping, understanding and learning how to challenge some of those negative distortions or negative views that you might have developed from the trauma and the difficulties you’ve gone through. 32:32 To relaxation training and self-control. 32:34 also learning how to do deep breathing and mindfulness and visualization as a way to create a different interior state of peace and calm. 32:48 Or we have to social problem solving, learning how to handle different situations and navigating social situations in a more effective way. 32:57 These are the core STL skills that we do in GBCBT. 33:00 And then we move on from there to the trauma-specific skills. 33:04 And these are psycho-ed about trauma. 33:06 So teaching about appropriate touch, sexual abuse, physical abuse, domestic violence, community violence, whatever is the specific issue, that’s what we have, you know, we provide psycho-ed about that. 33:18 If it’s a child who’s not experiencing community violence or domestic violence, we’re not going to get into that if it’s in the individual model. 33:25 We also kind of diverge by age. 33:28 For children in the elementary school age groups, a lot of times there’s an overlap between sexual abuse and physical abuse, so we will cover both physical abuse and sexual abuse. 33:38 And we have games that are psycho-ed games that reinforce that learning. 33:44 Then we go to what’s called basic disclosure. 33:47 Basic disclosure is like the first step in what we call exposure therapy, where you’re gradually exposing yourself to the reminders of the trauma or the thing that causes you fear or distress. 33:58 So basic disclosure, we’re asking them to talk about, or rather not talk about, we’re asking them to endorse and express specific elements of what they went through. 34:09 And then the advanced disclosure, they’re going to be going through it in a more comprehensive way. 34:15 This is where we get into what’s called the narrative therapy that’s very helpful in trauma-focused CBT, which is sort of like the parent of this model. 34:25 Then we get into personal safety skills, so learning what to do in different problematic situations and we wrap up with skills review and termination processing, kind of review the learning of the therapy, kind of do an activity where we do a letter writing activity where we kind of talk about what we learned in therapy and how we’re going to use what we learned to make better choices and live a better life going forward, so processing the end of therapy. 34:52 So this is kind of the this is the flow of the TV CBT bottle All right. Now we’re up to the game base CBT game examples. 35:00 This might be a good spot for a poll I don’t know if we have a poll in the queue we have Pull that says what do you think about CBT for trauma and then another one that is what is true about positive reinforcement systems? 35:21 Let’s use that one. What’s true about positive reinforcement systems? Let’s see if I can successfully touch on that. 35:30 Okay, so I just launched it. I’ll give it a few seconds. I’ll keep you updated. 35:36 Okay, should I keep going or should I wait for the poll to go? 35:40 Well, I would give it a sec. Let’s see what people respond with. 36:00 Okay, so far we have 100% that have voted positive reinforcement is the most effective behavior change. 36:09 Well, that’s good, especially since I don’t think I actually said that, but that is true and that’s the correct answer. 36:15 So yes, positive reinforcement is the most effective way to change behavior. 36:19 It is not a form of bribing to get good behavior. 36:22 I’ll have a lot of parents say, I feel like I’m bribing my kid by doing this kind of chart thing. 36:26 You can encourage parents to take the concepts of the positive reinforcement system and use it at home. 36:32 in fact, they should be doing that, and use it to reinforce the behaviors at home. 36:37 They’ll say, oh, is it bribing? 36:38 I say, no, it’s not bribing. 36:40 It’s bribing if you give them their reward before they do their work or their behavior. 36:45 But if you give them their reward after their work, then they’re earning a paycheck, right? 36:50 So no one’s bribing you to go to work. 36:51 You work for a week or two and then you get a paycheck, right, so you’re earning it, not just, not bribing it. 36:56 All right, so that’s just a side note. 36:59 So game-based CBT examples. 37:01 So, one example for rapport building or building relationships and breaking the ice is a getting to know you stack. 37:08 So, this game is probably one of the most favorite games that we do. 37:12 So, this game has a stack of cards. 37:15 Each card has two questions on it, a one-point question and a two-point question. 37:20 And people playing, we could do this in group, we could do it in individual therapy one-on-one, and you could do it with a family. 37:26 They can answer the one pointer or the two pointer or both for three points. 37:31 Therapist is playing the role as like MC, but the therapist also is involved and participating and does what we call strategic self-disclosure. 37:40 So I want the therapist to be playing these games along with the child because that makes them more accessible and relatable and it makes it more fun. 37:48 Getting to know you card games have those two points, those two different questions for a reason. 37:55 the one pointers are usually more simple like what’s your favorite color what do you want for your birthday and the two pointers are a little bit deeper like what was the saddest day of your life or what do you do when you’re when you’re angry or what do you want to learn in therapy so we’re incentivizing and encouraging the players to go a little bit deeper with their answers and their feelings of course they get more points the deeper they go and they get more superchecks and other fun stuff so again gamifying the participation all right The next game I have here is called Feelings Fast. 38:30 And this is a game that’s kind of a combination of Pictionary, or rather Win, Lose, or Draw. 38:38 Well, it looks like Pictionary, Charades, and Taboo. 38:41 So one part of this game, you play with a stack of feelings cards. 38:46 So each card has a feelings word on it. 38:50 And the players pick a card, and then there’s a separate stack that has the mode of expression. 38:56 The mode of expression could be drawing, it could be acting it out like you do in Shades, or it could be describing it without actually naming the word, and that’s kind of like taboo if you know that game. 39:06 So you pick a feelings card and you pick an expression card and then you have to get the other players to guess the feeling that you have on your card. 39:14 So let’s say I got a card that said happy and I pick draw, I’m probably going to draw a smiley face, that’s an easy one. 39:22 but I might get some card that says like you know ashamed and I get the card acted out so now I think get the other people to guess what the word is so oh how do I act out ashamed well maybe I’ll look like this and maybe I’ll kind of cover my head a little bit because when you’re ashamed it’s like a combination of guilty and embarrassed right so feelings fast you could play um you could also disentangle these different elements of the game drawing acting and talking and do it just as a one-off and it’s a really fun way to get kids talking about feelings and families talking about feelings and showing how they express those feelings talking about by language and facial expressions and it’s a really good like intro level game don’t say a word now this is kind of like feelings taboo so we have cards with one word that you’re trying to one feelings where you’re trying to get the other players to guess but then you have multiple synonyms underneath it you can’t use those synonyms and you’ve got to describe different situations like this is how I feel when I’m stuck in traffic oh angry frustrated mad yes you got it so you’re trying to get the other players to kind of guess it and then you get points or super checks or super bucks depending on what you’re doing for the positive reinforcement in order to do well in the game another fun emotional expression game then we move into coping skills, coping with difficult emotions. We teach about anger management. 40:52 We teach deep breathing and mindfulness. 40:54 And there’s a game called handoff madness that has, you know, various, there’s various iterations of. So one form of handoff madness we can have when it’s one-on-one. 41:06 You take a squishy ball or a ping pong ball. 41:09 You could also just grab a piece of paper and crumple it up into a ball. 41:13 And you have catch back and forth with them, with the other player or the other and we say, okay, our challenge is to get to 20 catches in a row. 41:21 But if we fail at that, if it falls and hits the ground, then we get really angry with the show, how we look when we get angry. 41:27 And then once we’re angry, we’ve got to recognize that and we’ve got to pretend to be doing one of our coping skills so we can pretend. 41:34 I’m really angry, the ball dropped. 41:36 Now I’m going to pretend to take some breaths or I’m going to pretend to read a book or ride a bike or listen to music, whatever it is. 41:43 And then you come back and you start at zero because it’s so frustrating, you’re messed up, you start at zero, and then you get to get back to throwing the ball back and forth. 41:50 You’re trying to get 20 or 30 or 40, whatever the goal is, catches in a row. 41:55 So handoff madness. 41:57 There’s other forms of it, but that’s the form that I find to be most fun in the individual context. 42:05 Wheel of knowledge. 42:06 This is a psycho-ed game. 42:08 So we have a pie wheel, kind of like in Trivial Pursuit. 42:12 You have your dice, you roll the dice, and you get a number. 42:15 So let’s say you roll the dice, you got number one. 42:17 So now you have to pick a card for answering a sexual abuse related question. 42:22 So a question might be, does sexual abuse happen to a lot of kids or not a lot of kids? 42:26 And the answer is it happens to a lot of kids. 42:28 It’s one in four girls and one in six boys, we project and say, yes, you did a good job. 42:34 So now you get a check mark in that wheel and then you keep playing. 42:38 And now all the players are playing and they have to answer multiple times. 42:41 Just like in Trivial Pursuit, And it takes a long time to fill up all the different pies on the pie chart. 42:47 So by the time everybody’s finished or whoever finishes and wins, you’ve answered many questions and the players have heard the other people answering these questions and you’re starting to really reinforce the knowledge and the information about the abuse or the trauma that was taught. 43:03 After Psycho-Ed, we move to basic disclosure. 43:05 We have who, what, where, and how. 43:07 This is actually a specific group model game, but I talk about it because it’s a very powerful exercise. So what we’re in a hat we have the kids together. 43:16 We give them three pieces of paper and we say we want you to write down who was the person that sexually abused you. 43:24 For example, if we’re doing a sexual abuse group, you know, where were you when it happened and how did they sexually abuse you? And we collect all these each round and we put it all together. 43:35 We put it in like a hat or a bucket and then we put it all together and then we get everybody in a circle and we’ll pick one card at a time and we’ll say, okay, let’s say who was sexually abused by a stepfather? 43:46 One kid will raise their hand or maybe another kid will raise their hand and we’ll say, okay, now we’re going to try to expand the number of hands that are near. 43:54 So a stepfather is somebody in the family, has anyone been sexually abused by someone in the family? 44:00 And then more hands will go up and then the last, you know, then the next expansion of circle would be keep your hands raised because we want everyone’s hands to be up. 44:12 Who is sexually abused by someone that they know? 44:14 Now pretty much every kid is going to raise their hands, it’s rare to be abused by someone that’s a complete stranger. 44:20 If that does happen then what you say is raise your hand and keep your hands raised if you are sexually abused. 44:25 And then if it’s a sexual abuse group by definition they’re in there because of that. 44:29 And the same would apply for other traumas, you would have a group that’s focused on that specific trauma. 44:34 The idea being that you’re trying to facilitate that aha moment that we are not alone and that this is a commonality of experience, which is in and of itself incredibly healing for people. 44:45 Who Wore and a Hat, great game. 44:48 Unlock the Path. 44:48 So this is an individual slash family model. 44:51 It’s a board game that we use to develop the trauma narrative. 44:56 So in this you have like a board game and the players have to work their way through the board. 45:00 Each level there’s six levels in this board in order to complete it and each level has multiple tasks So one test might be if you get that particular task You have to talk about what you were doing before the trauma happened or Draw a picture of the trauma happening or you know act out what you did after the trauma was over So there by the time you work through all the different tasks and challenges on this board and unlock the path to the next level all the way to the end. 45:32 You have had the kid go through multiple stages of talking about, drawing about, and acting out various aspects of this trauma in a safe and supportive environment, thus facilitating like greater healing and desensitization to the memories and the thoughts and the triggers of the trauma. 45:51 And you’ll also have lots of writings that can then be comprised into one of these trauma narrative booklets that can be a really valuable therapeutic product that they have at the end that they can refer back to and say, hey, I really made a lot of progress. 46:04 I remember going through this, I processed this trauma, I faced my fears, I learned a lot and now I feel like I can handle myself better in the future and I’m stronger and wiser for having gone through this process to really facilitate the development of that level of wisdom and insight. 46:23 And then we move to personal safety skill skits, so we do different scenarios that might be, you know, high risk or problematic, you know, situations where someone might be trying to abuse you or a situation that might be a little ambiguous and we rehearse and reinforce the idea of saying no and running away and telling a trusted adult what’s going on so that you can get help. 46:44 And we do this in the group program and with multiple ways. 46:48 will have the therapists will play potential abusers or traumatizing people and will have the kids respond appropriately and get help for it. 46:59 This again reinforces the key safety skills. 47:05 All right and then from there we have, well after that then we usually do our skills review and trauma processing. 47:15 Typically, I don’t have a slide for this, but a really good technique is doing like a goodbye letter, we call it. 47:21 So in a goodbye letter, we’ll say, okay, talk about your, talk about the difficulties you were having before therapy, and they’ll dictate to the therapist, and the therapist will write this stuff down or type it up and talk about what you learned in therapy. 47:34 And they’ll say, okay, I learned anger management and relaxation. 47:37 I learned to talk about my trauma, I learned safety skills, and I’ll talk about how you’re doing now. 47:41 Well, I feel better. 47:42 I feel more confident. 47:43 I feel happier. I feel more safe. And what are you going to do in the future? 47:46 I’m going to use these skills to live my best life.” And essentially has that kind of story arc to it. 47:51 And they have that goodbye letter, goodbye to therapy. 47:54 We have the caregivers come in and we share it with them. 47:57 We have them, before that, we also have them draw a picture of the child in the therapy. 48:01 And this is, again, something that a therapeutic product that they can take home with them and that it’s a meaningful thing that they can point to, help remind them of the good work that they did in therapy and the healing that they were able to accomplish. 48:14 So lastly, empirical research. 48:16 So we have done basic research on this, just comparing time one to time two and then three month follow-ups, and we’ve found that these GBCBT has been effective in helping in all the key therapeutic areas, internalizing, externalizing overall behavior problems, sexually inappropriate behavior and increasing knowledge of abuse and personal safety skills. 48:41 Gains were also maintained at three month follow up. 48:44 This was preliminary research and does not include control groups. 48:47 So at some point it would need to be, in order for it to be considered like an official, empirically supported treatment, it would have to go through multiple randomized control trials. 48:57 And that’s just something that we have not gotten to do. 49:00 But based on the work we have done in our own experience clinically, it’s a very, you know, fun and valuable treatment approach. So I think that brings us to the end. 49:11 There’s some selects of CBT publications that you can find. There’s also a book. 49:19 And with that, I don’t know if we want to do questions or if we need to do another poll, you tell me. Yeah, no, we can start with questions. 49:28 All right, so we have 10 minutes for questions. 49:30 Okay, awesome. So first and foremost, thank you so much, Dr. Mizerel. We’re going to hop into Q &A. First, I’ll ask the submitted questions, and then we’ll switch to the verbal Q &A, which is when we’ll stop the recording. 49:42 So a couple of questions that we have that were submitted are, what is the difference between game-based CBT games and traditional play therapy? 49:56 All right. Great. Great question. So traditional play therapy is like less directive. 50:04 So be like coming into my room and you’ll see all these toys here and you’ll see games and stuff from the on the wall. 50:12 And the way the flow goes there is like, all right, let’s pick something that you want to do. And while you pick this stuff that you want to do, we’ll play together. 50:19 Like we’ll play with the toys, we’ll play with the Barbie dolls, we’ll play Uno or Django, whatever. 50:24 And we’ll talk while doing it. 50:25 So play therapy traditionally is more client-directed, like what the client, the kid wants to do, the therapist is going with them and developing this therapeutic relationship and establishing trust. 50:36 And then through that process, the hope is that while we talk and play, the defenses are reduced and the child will talk to us more. 50:43 The game-based CBT approach is different because it’s structured. So it’s like today, here’s the plan, here’s the agenda. 50:49 It’s not client-directed, it’s therapist-directed. 50:52 And here’s the specific activities that we’re going do and their therapeutic activities, we have the rules at the beginning of the game, rules at the beginning of the session, they’re earning the prizes at the end if they’ve earned enough, if they didn’t earn the prize or not getting the prize, so it’s just much more structured and regimented. 51:11 That’s the big difference. 51:14 Another question that we have, can therapists pick and choose to use the games without adhering to the whole game-based CBT approach? 51:25 Yeah, absolutely. 51:26 That’s probably how most people use it to be honest with you Because to do the full thing is very involved and you got to really learn it and you got to be kind of trained on it But if you just pick up the book, it’s like a cookbook like you could just delve into it and say hmm I’m looking for some good Coping skills ideas. 51:45 So I’m gonna just pick up this book and read the coping skill chapter and use the games from there in my So yeah, you can do the game-based CBT strategies can be used outside of doing the whole comprehensive model in a formal kind of way. 52:04 So before we switch to verbal questions for those who are watching the recorded version, thank you so much for attending. 52:11 Please complete the exit survey and archive recording of this webinar will be posted to our website njcts.org under the programs tab. 52:19 The blog is now open and accessible under the archive webinar. 52:23 All questions submitted during the recorded viewing will be posted there. 52:27 Our presenter will be answering all questions posted until Tuesday, March 4th. 52:31 Any personal information will not be included. 52:33 Our next presentation will be on mindfulness presented by Dr. Anton Shcherbakov. 52:39 It’s scheduled for Wednesday, March 26th at 7 p.m. 52:43 with the recording the following day, Thursday, March 27th at 2 p.m. 52:48 Eastern Standard Time will be offering professional development certificates for school professionals and school nurses that attend the live or recording of the webinar. 52:56 To register for either time, please visit njcts.org slash webinars. 53:01 And with that, I’m going to stop the recording.